While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record?

Left-sided heart failure

Myocardial ischemia

Right-sided heart failure is systemic and results in peripheral edema, weight gain, and distended neck veins

Atrial fibrillation

Answer and Explanation

The Correct Answer is A

A. Left-sided heart failure: Left-sided heart failure causes pulmonary congestion leading to crackles, orthopnea (difficulty breathing while lying flat), and paroxysmal nocturnal dyspnea (waking up gasping for air).

B. Myocardial ischemia: Myocardial ischemia causes chest pain, shortness of breath, and fatigue, but it does not cause crackles in the lungs or fluid overload symptoms.

C. Right-sided heart failure: Right-sided heart failure results in systemic congestion (peripheral edema, weight gain, and jugular vein distention), not pulmonary symptoms like crackles.

D. Atrial fibrillation: Atrial fibrillation causes irregular heartbeats, palpitations, and fatigue, but it is not the primary cause of crackles or orthopnea.

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Correct Answer is D

Explanation

A. Stage IV: Stage IV ulcers involve full-thickness skin loss with exposed bone, tendon, or muscle. Since this ulcer is shallow and pink without slough, it is not Stage IV.

B. Stage I: Stage I ulcers are intact skin with non-blanchable erythema. Since the ulcer is open, it is not Stage I.

C. Stage III: Stage III ulcers have full-thickness tissue loss, possibly exposing subcutaneous fat. The given description lacks fat exposure or depth, ruling out Stage III.

D. Stage II: Stage II pressure ulcers involve partial-thickness skin loss with a shallow open wound, pink/red wound bed, and no slough. The given description matches Stage II.

A. "I will treat all the family members to be on the safe side." B. "My child must be free from nits before returning to school." C. Toys that can't be dry cleaned or washed must be thrown out." D. "All recently used clothing, bedding, and towels must be washed in hot water."

Correct Answer is D

Explanation

A. "I will treat all the family members to be on the safe side." Treatment is only recommended for individuals who have active lice or close, prolonged contact with the infected child. Treating everyone unnecessarily may lead to overuse of medications.

B. "My child must be free from nits before returning to school." The CDC and AAP do not recommend "no-nit" policies, as nits alone do not indicate active infestation. Children can return to school after appropriate treatment begins.

C. "Toys that can't be dry cleaned or washed must be thrown out." Non-washable items should be sealed in a plastic bag for 2 weeks to kill lice, rather than being thrown away.

D. "All recently used clothing, bedding, and towels must be washed in hot water." Lice and nits can survive on fabric surfaces, so washing clothing, bedding, and towels in hot water (≥130°F/54°C) and drying on high heat is recommended to eliminate them.

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Naxlex Comprehensive Predictor Exams

The nurse admitting an older patient notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?

Correct Answer is D

Explanation

A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching?

Correct Answer is D

Explanation

Which action by a nurse indicates application of the critical thinking model to make the best clinical decision?

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